INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, VOL. 9: 525-529 (1994)

DAY HOSPITALS: THE CASE IN FAVOUR ROBERT HOWARD

Lecturer in the Psychiatry of Old Age, Section of Old Age Psychiatry, Institute of Psychiatry, De Crespigny Park, Camberwell, London SE5 8AF, UK

SUMMARY

The day hospital constitutes an integral and valued component of the old age psychiatry service provided by the majority of units in the United Kingdom. Changes in the political climate, vogues for alternative forms of care provision and a lamentable lack of hard evidence that day hospitals present the best use of resources have led to serious questioning of their future by most who have written in recent years on the subject. The issue should not be ‘day hospitals are wonderful; other systems are not’ (or vice versa), but that the day hospital should be seen as an available option with its own particular benefits alongside other hospital-based and community components of a good service. Advocates of day hospitals should continually review staffing mix and structure to ensure the best use of professional skills.

KEY woms-Day hospitals, psychiatry, geriatrics, psychogeriatrics.

Day hospitals are very much part of the old age psychiatry landscape, consequently their value and superiority relative to alternative forms of service delivery are sometimes uncritically assumed. Such apparent complacency has invited serious question- ing of the worth of day hospitals: does their func- tion overlap with that of other bodies who run day services and can alternative care models do a better job at less cost?

Neither side in this debate has powerful evidence to fuel their argument. Day hospital provision is expensive, costing more than outpatient or G P fol- low-up, day centre attendance or perhaps even inpatient care (Gerard, 1988; Ross, 1976; Tucker er af., 1984). Undoubtedly, some low-intensity activities that could be performed by unskilled staff in day centres do take place in day hospitals and attendance for some patients may have a primarily social function (Ball, 1993; Gerard, 1988; Thomp- son, 1990). Day centres, however, have traditio- nally failed to make any impact upon the psychiatric system because of either a lack of com- mitment by local authorities or a general failure of liaison between hospital and the community (Vaughan, 1985). The increasingly fragmentary dis- position of mental health services that has accom- panied the current move away from hospitalcentric models has created a very different potential place for the day hospital than the one occupied in the 1950s and 1960s, when day hospitals were them-

selves in vogue (Carse et al., 1958). What may be forgotten in the current political and economic cli- mate is that while it may be possible to carry out many of the activities that have to date been seen as the remit of the day hospital by other and cheaper means, the day hospital is hard to beat at least seven of these.

ALTERNATIVE TO INPATIENT ADMISSION

There is little evidence to suggest that the avail- ability of a day hospital to an old age psychiatrist actually reduces the number of patients that he or she deems necessary to admit to inpatient care. In defence of the old age psychiatry day hospital, it has to be said that this is largely a consequence of the lack of studies performed in recent years in this area. Historically, day hospitals evolved as apparently successful alternatives to inpatient admission (Carse et af., 1958). Data are only avail- able from recent studies which have included acutely ill young psychiatric patients and it may not be appropriate to extrapolate these to the psy- chogeriatric situation. As many as 40% of such patients, however, can be satisfactorily treated in a day hospital setting (Creed et al., 1989, 1990) rather than being admitted as inpatients. At 3- and 12-month follow-up the overall benefits of day hos-

CCC 0885-6230/94/070525-05 0 1994 by John Wiley & Sons, Ltd.

Received 27 Seprember 1993 Accepted25 October 1993

526 R. HOWARD

pita1 attendance are equivalent to those of inpatient care (Creed et al., 1991).

Regardless of the lack of published studies, most old age psychiatrists who have access to a day hos- pital would claim that they use that facility as an alternative to inpatient admission in two principal ways. First, admission to the day hospital for assessment, brief treatment programmes or even for longer periods is ideal for those patients who need more than outpatient clinic or CPN super- vision and would otherwise require inpatient admission. Second, discharge from the inpatient wards can be made earlier using the day hospital as a halfway house while the patient gains confi- dence and competence at home and the network of social and practical supports that was disrupted by admission is reestablished. No matter how care- fully a discharge date is planned and advertised in advance, the home help, CPN, district nurse or other components of community support rarely move in to provide a service which ‘seamlessly’ picks up where the hospital left off.

INVESTIGATION, ASSESSMENT OR SHORT FOLLOW-UP

The age of the big psychiatric institution is over and placements are now made in a variety of scat- tered facilities administered by private, voluntary and statutory bodies. The importance of adequate preplacement assessment before patients are ‘lost’ to what remains of centralized old age psychiatric services thus cannot be overstated. The increasing need for such detailed assessment represents a novel role for day hospitals and one that was not envi- saged 20 or 30 years ago when many of them were established.

The day hospital also provides an ideal venue for a programmed investigative package which might be otherwise impractical to perform in the clinic. For example, a detailed neurological exam- ination, CT or MR scan and EEG could be arranged through the outpatient department, but it is altogether easier for an elderly patient to attend the day hospital on one or two occasions.

For those patients who may require more inten- sive assessment of, say, apparently elevated mood or brief periods of confusion than can be carried out in the clinic or by the home team, day hospital attendance for a limited assessment period may be more acceptable to the patient and her family than inpatient admission.

Finally, the day hospital provides an excellent environment for the short-term follow-up of recently discharged inpatients, those in acute crises and in the period following major treatment changes.

CARER SUPPORT IN DEMENTIA

Available evidence does not support the notion that day hospitals reduce admissions of demented patients to residential or inpatient care (Ballinger, 1984; Diesfeldt, 1992; Woods and Phanjoo, 1991). The difficulties inherent in testing such a thesis, however, are apparent and complicated further by the observation that establishment of a day hospital may represent an extra resource for a population of patients not already in receipt of services (Ball- inger, 1984).

Relief of strain on those who care for demented patients in their homes has always been an import- ant goal for psychogeriatric day hospitals (Peace, 1982; Sands and Suzuki, 1983) which they achieve in the majority of relatives (Gilleard, 1987). Since the morale and ability of carers appears to be the most important factor in determining whether or not demented patients can be maintained in the community (Jerrom et al., 1993; Woods and Phan- joo, 19911, it is surprising that this perceived benefit is not reflected by lower rates of admission to long- term residential care. It may well be that as disabi- lity in dementia progressively worsens at much the same rate, whatever the setting of care (MacDonald et al., 1982), time taken to reach the point when a patient needs admission, regardless of available support, is a constant. Day hospital attendance may not therefore have prevented or delayed admission, but the quality of the lives of both the patient and the carers during the time leading up to that admission may have been beneficially affec- ted. Such benefit would be very difficult to quantify from admission data or put a monetary value to.

REHABILITATION, MAINTENANCE AND REGULAR REVIEW

A majority of those old age psychiatrists who have access to day hospital facilities believe that the day hospital has a very different role from that of a local authority day centre (Beats et al., 1993). In

DAY HOSPITALS: THE CASE IN FAVOUR 527

particular, day hospitals are appropriate venues for ‘high-intensi ty’ rather than ‘low-intensity’ activities (Gerard, 1988). High-intensity activities are those which are rehabilitative and restorative and would include treatments of functional psychiatric dis- orders and of the behavioural and cognitive symp- toms of demented patients. Inevitably, some low- intensity activities (support and education of carers, monitoring and maintenance of the chroni- cally mentally ill and maintenance of social con- tacts) are carried out in day hospitals in tandem with those of higher intensity since such needs will coincide in individual patients.

MAINTENANCE OF COMMUNITY LINKS DURING ADMISSION

Admission to an inpatient bed for even a brief per- iod of time will result in some degree of disruption of the supportive network that surrounds an elderly individual in the community. At the point of dis- charge it may prove difficult to reestablish contact with friends and relatives who were previously reg- ular visitors as well as professional supports such as home helps, community nurses and social workers. Day hospital attendance, particularly if this can be arranged on consistent days in the week, can be assimilated with only minimal disruption to the patient’s routine and network of supports.

ALTERNATIVE TO LONG-TERM RESIDENTIAL CARE

An often repeated criticism of old age psychiatry day hospitals is that they tend to provide relatively long-term support for a particular group of the elderly mentally ill (Ball, 1993; Thompson, 1990). Patients with mild to moderate dementia, those with long-standing neurotic difficulties or chronic affective illnesses may all accumulate in day hospi- tals and continue to attend for several years. This is not necessarily a bad thing, particularly if the alternative to this situation is admission to long- term residential care. Few of us would have diffi- culty in making the choice between admission to an old people’s or nursing home and the chance to continue living in our own homes with day hospi- tal support.

Old age psychiatry day hospitals thus tend to

accumulate chronic patients in marked contrast to geriatric medical day hospitals, in which a certain momentum is generated by the continuous turnover of patients (Martinez et al., 1984). Attempts to com- pare the effectiveness of geriatric medical and psy- chiatric day hospitals using the same activity indices will inevitably reflect poorly on the psychi- atric ones since most of such measures are based on the concept of an optimal duration of stay and are derived from dividing some measure of new attendances by total attendance (Martin and Mil- lard, 1975; Kong, 1991). In the assessment of psy- chogeriatric day hospitals, measures of so-called ‘efficiency of process’ such as mean turnover time and average length of stay, although obviously of importance, cannot be directly compared with the results from physical medicine. Further, there are as yet no assessment measures of day hospital activity and efficiency which can truly claim to identify and measure the therapeutic and social aspects of care delivered. We are thus left with a range of unmeasurable potential benefits specifi- cally associated with long-term attendance and consequent reduced efficiency of old age psychiatry day hospitals. Among these would be the develop- ment of so-called ‘prosthetic bonds’ (a horrible term, but we all recognize what it describes) formed with the day hospital which are often sufficient to maintain a patient and her carers at home (Arie, 1975). Long-term day hospital care is also an important means of monitoring change in chronic disability so that flexible and rapid action can be taken in response to deterioration or periods of crisis (Wilkinson, 1992).

SERVICE MORALE AND RECRUITMENT

The importance of day hospitals in the maintenance of morale across an old age psychiatry service should not be underestimated or belittled since they are often the components of a service where staff satisfaction and happiness are highest. Since rota- tional movements of staff between different wards and community teams will occur and members of several disciplines work in the day hospital as well as other parts of the service, there is a great poten- tial for morale enhancement. Many workers in a variety of disciplines involved in the care of the elderly mentally ill (including the author) were first attracted to such work following exposure to a day hospital.

528 R. HOWARD

THE FUTURE

The articulate and influential opponents of the day hospital in old age psychiatry suggest that day hos- pitals represent an expensive and anachronistic form of patient management and that available resources should be invested in alternative models of service delivery. For those of us who believe that day hospitals offer both good value and the delivery of a particular kind of care that community teams or local authority day centres simply cannot match (Beats et al., 1993), it is no longer adequate to do no more in the defence of the day hospital than to repeatedly assert our views. In response to the (sometimes fair) criticism that day hospitals are often wastefully overstaffed with underutilized professionals, staff mixture and structure should be regularly reviewed with particular regard to the competing needs of other areas of the service. Data are needed to support the pro-day hospital position and properly designed studies (rather than mean- ingless audits) of the activity and effectiveness of day hospitals are long overdue. Donaldson et ul. (1986) have suggested a research strategy which involves the kind of randomized clinical trial approach that has been used in the evaluation of psychiatric day hospitals for young patients through comparison with alternative services. Information, these authors suggest, should be col- lected in four main areas:

Comparisons of outcomes for subgroups of day hospital patients with similar subgroups utiliz- ing alternative models of care Costing of each patient’s consumption of care within treatment and subsequent service use over a determined time period Standardized collection of clinical, social and psychological outcome data and measures of dependency at beginning, during and at end of study period Some measure of patient and carer satisfaction with treatment received

Until the results of such studies are renorted. neither side in the debate on the future of h e day hospital in old age psychiatry can truly speak with informed authority. The responsibility of those who would advocate the absolute replacement of day hospitals by alternatives such as community mental health teams is to assess the effectiveness of such models of service delivery with the same rigour they might demand of day hospital evalu- ation studies.

ACKNOWLEDGEMENTS

Thanks to Drs Chris Ball, John Kellett and Pro- fessor Peter Millard for pointing me towards the relevant day hospital literature and to Professors Raymond Levy and Elaine Murphy and Dr Klaus Bergmann for their improvements to a draft manu- script.

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